Camp Registration 2020
Name: *
Gender *
Birthday *
MM
/
DD
/
YYYY
Age at camp *
Grade Completed
Mailing Address *
Parents Name/Names *
Email *
Home Phone Number *
Emergency Phone Number *
Home Church
Is a church or organization giving you a scholarship? (If Applicable)
Clear selection
If you have a scholarship who is covering your scholarship? (If Applicable)
Contact name for your scholarship? (If Applicable)
Contact phone number for your scholarship? (If Applicable)
Scholarship Amount? (If Applicable)
T-Shirt Size *
Is your tetanus shot up to date? *
Allergies, if yes, what are your allergies?
Does you take any medications, if so which ones?
Which Camp Will Your Child Attend?
Clear selection
Upon arrival at Camp Assurance you will need to sign a copy of the following Parent/Camper Statements.
Parent Statement: I understand that our personal insurance is the primary coverage for my child and that each camper is covered by limited insurance. In case of emergency I give the camp permission to prescribe medication and secure treatment for my child's care. The camp will contact me as soon as possible. i will not hold Camp Assurance or its staff responsible in case of accident or illness. I give my permission for my child to participate in all camp activities including trips away from the campgrounds.

Camper Statement: I will cheerfully obey the camp rules and conduct myself as I am instructed. I also agree to follow camp's clothing guidelines. By my signature I agree to be held accountable to this statement.
Payment - Due to Covid 19, all camps begin with a 1 day camp at Camp Assurance with online follow-up throughout the week. Freewill donation will be available at registration. Disregard prices below. *
Online Payment
In light of the uncertainty caused by the COVID-19 Crisis, residential camps will not be held this year. The first day of each camp will be a 1 day camp, and the rest of the week will be online and phone follow up.
Checks that have already been sent to Rozanne Hintz PO Box 7 Dixon, NE 68732 will not be cashed, but there will be a chance for a freewill donation at the time of registration for each 1 day day camp.
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